Arlene Goodman

The incidence and potential pathomechanics of patellofemoral pain in female athletes

BACKGROUND The aims of this study were to determine the prevalence and incidence of patellofemoral pain (PFP) in young female athletes and prospectively evaluate measures of frontal plane knee loading during landing to determine their relationship to development of PFP. We hypothesized that increased dynamic knee abduction measured during preseason biomechanical testing would be increased in those who developed PFP relative to teammates who did not develop PFP. METHODS Middle and high school female athletes (n=240) were evaluated by a physician for PFP and for landing biomechanics prior to their basketball season. The athletes were monitored for athletic exposures and PFP injury during their competitive seasons. FINDINGS At the beginning of the season, the point prevalence of PFP was 16.3 per 100 athletes. The cumulative incidence risk and rate for the development of new unilateral PFP was 9.66 per 100 athletes and 1.09 per 1000 athletic exposures, respectively. All new PFPs developed in middle school athletes who demonstrated mean International Knee Documentation Committee score of 85.6+/-7.7 at diagnosis. The new PFP group demonstrated increased knee abduction moments at initial contact (95% CI: 0.32 to 4.62Nm) on the most-symptomatic limb and maximum (95% CI: 1.3 to 10.1Nm; P=0.02) on the least-symptomatic (or no symptoms) limb relative to the matched control limbs. Knee abduction moments remained increased in the new PFP group when normalized to body mass (P<0.05). INTERPRETATION The increased knee abduction landing mechanics in the new PFP group indicate that frontal plane loads contribute to increased incidence of PFP.

Vision Diagnoses Are Common After Concussion in Adolescents

Objective. To determine the prevalence of vision diagnoses after concussion in adolescents. Methods. Cross-sectional study from July 1, 2013 to February 28, 2014, of patients aged 11 to 17 years with concussion evaluated in a comprehensive concussion program. Results. A total of 100 adolescents were examined, with a mean age of 14.5 years. Overall, 69% had one or more of the following vision diagnoses: accommodative disorders (51%), convergence insufficiency (49%), and saccadic dysfunction (29%). In all, 46% of patients had more than one vision diagnosis. Conclusions. A high prevalence of vision diagnoses (accommodative, binocular convergence, and saccadic eye movement disorders) was found in this sample of adolescents with concussion, with some manifesting more than one vision diagnosis. These data indicate that a comprehensive visual examination may be helpful in the evaluation of a subset of adolescents with concussion. Academic accommodations for students with concussion returning to the classroom setting should account for these vision diagnoses.

Characteristics of Prolonged Concussion Recovery in a Pediatric Subspecialty Referral Population

OBJECTIVE To identify pre-existing characteristics associated with prolonged recovery from concussion in a sample of patients referred to a pediatric sports medicine clinic. STUDY DESIGN This was a retrospective, exploratory cohort study of 247 patients age 5-18 years with concussion referred to a tertiary pediatric hospital-affiliated sports medicine clinic from July 1, 2010, through December 31, 2011. A random sample of all eligible patient visits (3740) was chosen for further review and abstraction. Statistical comparisons between subsets of patients were conducted using exact χ(2) tests, logistic regression, quantile regression, and Kaplan-Meier survival curves. RESULTS The median time until returning to school part-time was 12 days (IQR 6-21); until returning to school full-time without accommodations was 35 days (IQR 11-105); until becoming symptom-free was 64 days (IQR 18-119); and until being fully cleared to return to sports was 75 days (IQR 30-153). Furthermore, 73% of all patients were symptomatic for >4 weeks, 73% were prescribed some form of school accommodation, and 61% reported a decline in grades. Characteristics associated with a prolonged recovery included a history of depression or anxiety; an initial complaint of dizziness; abnormal convergence or symptom provocation following oculomotor examination on physical examination; and history of prior concussion. CONCLUSIONS Pediatric and adolescent patients with concussion may experience cognitive and emotional morbidity that can last for several months following injury. Clinicians should consider specific pre-existing characteristics and presenting symptoms that may be associated with a more complicated recovery for concussion patients.

Vestibular Deficits following Youth Concussion.

OBJECTIVE To characterize the prevalence and recovery of pediatric patients with concussion who manifest clinical vestibular deficits and to describe the correlation of these deficits with neurocognitive function, based on computerized neurocognitive testing, in a sample of pediatric patients with concussion. METHODS This was a retrospective cohort study of patients ages 5-18 years with concussion referred to a tertiary pediatric hospital-affiliated sports medicine clinic from July 1, 2010 to December 31, 2011. A random sample of all eligible patient visits was obtained, and all related visits for those patients were reviewed. RESULTS A total of 247 patients were chosen from 3740 eligible visits for detailed review and abstraction; 81% showed a vestibular abnormality on initial clinical examination. Those patients with vestibular signs on the initial examination took a significantly longer time to return to school (median 59 days vs 6 days, P=.001) or to be fully cleared (median 106 days vs 29 days, P=.001). They additionally scored more poorly on initial computerized neurocognitive testing, and it took longer for them to recover from neurocognitive deficits. Those patients with 3 or more previous concussions had a greater prevalence of vestibular deficits, and it took longer for those deficits to resolve. CONCLUSION Vestibular deficits in children and adolescents with a history of concussion are highly prevalent. These deficits appear to be associated with extended recovery times and poorer performance on neurocognitive testing. Further studies evaluating the effectiveness of vestibular therapy on improving such deficits are warranted.

Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent Concussion

Most pediatric and adolescent concussion patients will heal within 1 month. However, 10% to 20% of adolescent concussions will take longer than 1 month to heal. In this subgroup, prolonged symptoms might include vestibular system deficits, residual neck muscle whiplash injury, exercise intolerance/dysautonomia, and memory issues. At this stage in recovery, these problems respond better to “active rehabilitation” via specific targeted strat egies rather than to strict rest. During follow-up office visits, a careful history and physical exam can elicit specific deficits

Concealed degloving injury (the Morel-Lavallée lesion) in childhood sports: a case report.

Morel-Lavallee lesions (MLLs), described in 1853 by Maurice Morel-Lavallee, are uncommon closed internal degloving injuries in which the subcutaneous tissues are stripped off the fascia with a hematoma and, in some cases, necrotic fat1-4. These lesions are most commonly noted with high-energy pelvic trauma1,3 and can require weeks to resolve. Accurate diagnosis is delayed in up to one-third of patients because of inconsistent clinical presentation and because initial skin bruising can mask the importance of the underlying soft-tissue injury5. These lesions occur less frequently in the knee region; knee MLLs have been reported in professional football players6. A few reports1,6,7 in the literature indicate that MLLs most commonly occur in people in their third and fourth decades of life. In 1986, Letts8 documented cases of degloving injuries in children following major trauma; we report the rare case of a boy who presented with an MLL two weeks after a football injury. The patient and parents were informed that nonidentifying information from the case would be submitted for publication, and they provided consent. While playing outdoor pick-up football, an eleven-year-old boy sustained a left knee injury after being tackled and falling onto the asphalt, landing directly on the anterior aspect of the knee. He was not wearing any protective padding at the time of injury. He developed left thigh and knee pain as well as a large bruise about the thigh and was taken to the local emergency department. He was healthy with no medical problems. On presentation, he had fully intact neurologic and vascular function in the lower extremities and had 5 of 5 hip and knee flexor and extensor strength despite some pain. He had moderate pain with knee motion, with an …

Oculomotor and neurocognitive assessment of youth ice hockey players: baseline associations and observations after concussion

Baseline scores on the King-Devick (K-D) Test, Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), Sport Concussion Assessment Tool 3 (SCAT3), and convergence were evaluated in youth hockey players. Worse K-D times were associated with worse ImPACT visual motor speed and reaction time. Eleven concussed athletes were retested, and there was a trend toward improved ImPACT and K-D times compared to baseline.

Common Lower Extremity Injuries in the Skeletally Immature Athlete

Lower extremity musculoskeletal pain is a common complaint in the adolescent athlete. During rapid growth, several common biomechanical changes occur that may predispose to overuse injury. Unlike fractures, most of these office-based sports medicine complaints are initially evaluated by the primary care provider. This review discusses several of the most common complaints and briefly discusses some clinically significant conditions that masquerade as common injuries. The article discusses only the injuries unique to the growing athlete. The articles goal is to help develop a framework for the pediatric clinician to evaluate common complaints and formulate a plan that includes simple stretches and physical therapy recommendations.